Evans, Sheila • :il'.ir:Z.♦bat ...... ..
TO` +N OF QUEEN BUP*
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �' A /XI
Name f,.lt 3 Case #3
Date of Cremation —4p�—!/ —!R
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Time Cremation Started
Time Cremation Completed r �
Type of Container
Remarks :
Am N av leme R 01q f��� � 611 J
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05/03/1995 15:25 F1S-792-1287 REGAI&DENAY #1345 PANE 05
V
TOWN Or GUEEt 913URY
tjwt view CE1e7E[tY
�4
t;;�trzur rut:t ur�t
UuaE<er Roadt queenibur y, t4t*# York r�pi34
Phone t518) Crematorium 745-4477 sr it 110 anycirr
Cemetery 74;-4476
14UTHUN I ZAT I ON TO CREMATE
The undersigned requests and authurires Piny View Cr-vw&t0riu4A, in
occvrdance with anq jut:'ect to it, Rules and Reg kAIotio+rs to
ci-12*ate bhe remasns oFk
(Name) l9*x)
t5treetI (Cit- yi t3td�lp ili Goc#Fl
r�
who died on ;�h1s� - --Way of fb`iH 19
(Place)
Nance and a44ress of r,earost 1 wing relat ivt: ue nab* of pot^SOri
o%At:horizing cremation:
Relationship to the dece^sed,_
Name of Funerai Home
IMPORTAIM
I represent that to the best of my knowledVer thr decep#od has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full powvr and authori sat i on to arra►I9tt
for the cremation of the remains and to direct the dispositiOn of
the Crenated remains, that any personal posses%tons have either
bo to removed at% may be destroyed, and agree to pr-ottir t f drfend
and save harmless Pine View Creaatt)rium from any and all (:Balms
and demand* for loss or damages which may be made against thin oy
rtasoti of or connected with the cremation Of said resolos as
dfrected, whether such Claims or dtaends are or are not vohoiiy
groundless, false or Fraudulent.
iNi}�ness) t�tlde-Qss)